Spinal surgery and spinal procedures in adults

Spinal surgery and spinal procedures in adults - Guideline for Antimicrobial Prophylaxis

Publication: 30/07/2010

Next review: 16/06/2023

Clinical Guideline

CURRENT

ID: 2070

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis during spinal surgery and spinal procedures in adults.

Summary table of routine recommendations
Background information
Special antimicrobial prophylaxis recommendations
References

Summary table of routine recommendations

Procedure	Prophylaxis recommended	Evidence level	Prophylaxis intended to reduce	NNT	Antimicrobial dose/route ≤ 1 hours before procedure
Procedure	Prophylaxis recommended	Evidence level	Prophylaxis intended to reduce	NNT	Routine	MRSA risk# or penicillin allergic
Open spinal surgery with or without instrumentation.	YES	A (1-3)	SSI	28	Flucloxacillin 1g iv plus Gentamicin 2mg/kg iv IBW both single dose*	Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose
Minimally invasive disc surgery (e.g. microdiscectomy)	YES	A (1-3)	SSI	28	Flucloxacillin 1g iv plus Gentamicin 2mg/kg iv IBW both single dose*	Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose
Reoperation within 1 month (NB consider recent microbiology and discuss if required)	YES	D	SSI	-	Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose	Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose
Radiologically guided spinal biopsy, discography or radiofrequency ablation of spinal tumours	NO	D	-	-	-	-
Vertebroplasty	NO	D	-	-	-	-
Other percutaneous procedures e.g. facet joint injection, epidural injections	NO	D	-	-	-	-

Table 1. Summary of routine antimicrobial prophylaxis recommendations for spinal surgery and procedures. NNT, number needed to treat; *redose Flucloxacillin at 4 hours if operation lasts ≥ 4 hours. NB. It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to give them within the hour before incision.

Gentamicin dosing in adult male >16 years				Gentamicin dosing in adult female > 16 years
Use height to select Gentamicin dose	IBW from height (kg)	Use ABW if less than IBW (kg)	Gentamicin dose (mg)	Use height to select Gentamicin dose	IBW from height (kg)	Use ABW if less than IBW (kg)	Gentamicin dose (mg)
6’ 3” (1.9m) +	84.5	78 to 82	160	6’ 3” (1.9m) +	79.5	78 to 82	160
6’ 2” (1.88m)	82.2			6’ 2” (1.88m)	77.2	72 to 77	150
6’ 1” (1.85m)	79.9			6’ 1” (1.85m)	74.9
6’ (1.82m)	77.6	72 to 77	150	6’ (1.82m)	72.6
5’ 11” (1.8m)	75.3			5’ 11” (1.8m)	70.3	66 to 71	140
5’ 10” (1.78m)	73			5’ 10” (1.78m)	68	66 to 71	140
5’ 9” (1.75m)	70.7	66 to 71	140	5’ 9” (1.75m)	65.7	60 to 65	130
5’ 8” (1.72m)	68.4			5’ 8” (1.72m)	63.4
5’ 7” (1.7m)	66.1			5’ 7” (1.7m)	61.1
5’ 6” (1.67m)	63.8	60 to 65	130	5’ 6” (1.67m)	58.8	55 to 59	120
5’ 5” (1.65m)	61.5	60 to 65	130	5’ 5” (1.65m)	56.5
5’ 4” (1.62m)	59.2	55 to 59	120	5’ 4” (1.62m)	54.2
5’ 3” (1.6m)	56.9			5’ 3” (1.6m)	51.9	49 to 54	100
5’ 2” (1.57m)	54.6			5’ 2” (1.57m)	49.6	49 to 54	100
5’ 1” (1.55m)	52.3	49 to 54	100	5’ 1” (1.55m)	47.3	43 to 48	90
5’ (1.52m) or under	50	49 to 54	100	5’ (1.52m) or under	45	43 to 48	90

Table 2. Guidance for dosing Gentamicin for prophylaxis. IBW, ideal body weight; ABW, actual body weight.

Background information

The continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in Leeds, the ongoing problem of Clostridium difficile infection and several severe deep-seated spinal infections with multi-resistant Gram-negative bacilli has prompted a review of surgical prophylaxis. In addition, updated guidelines on surgical prophylaxis have been published by the Scottish Intercollegiate Guideline Network and the National Institute of Heath and Clinical Excellence.

The aim of antimicrobial prophylaxis when used in spinal surgery is a reduction in surgical site infection (SSI) - a potentially debilitating and occasionally life-threatening complication. However, because of the increasingly recognised adverse effects of antimicrobial use, prophylaxis should only be used where there is clear evidence or consensus that the benefits outweigh the risks.

Infection rates following spinal surgery without instrumentation is low <3% but is higher in surgery involving instrumentation and can exceed 10% (4). Infection rates varied between 1.5 and 8.5% in a meta-analysis of studies evaluating prophylaxis for spinal surgery (1).

Staphylococci(including Staphylococcus aureus and coagulase negative staphylococci) are the most common cause of deep-seated infection following spinal surgery. Enterobacteriaceae (“coliforms”), enterococci, streptococci and Pseudomonas spp. and members of skin flora e.g. propionibacteria are reported to cause a small percentage.

Staphylococcus aureus is the most common cause of post operative surgical wound infections.

It is recommended to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (2, 3). Expert guidelines from the British Society for Antimicrobial Chemotherapy recommends use of glycopeptides prophylaxis in patients with a history of MRSA colonisation or infection

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

Special antimicrobial prophylaxis recommendations

Spinal surgery
A meta-analysis of antimicrobial prophylaxis for spinal surgery demonstrated a benefit for prophylaxis, where the individual studies had failed to show a significant benefit (1). There was no advantage to using antimicrobials with anti-Gram negative coverage or with multi-dose regimens.

Since Staphylococcus aureus remains the most common cause of wound infection, against which prophylaxis is aimed, flucloxacillin is recommended as primary prophylaxis, with teicoplanin as an alternative in penicillin allergic patients and those at high risk of MRSA infection. Teicoplanin has the advantage of bolus administration, compared to the prolonged intravenous infusion of vancomycin that is likely to hinder compliance and more rapid penetration into nucleus pulposus.

Flucloxacillin and Teicoplanin lack any Gram negative cover. Although the meta-analysis showed no benefit for Gram negative cover, the occurrence of several Gram negative deep spinal infections and a desire to cover coagulase negative staphylococci (which are usually resistant to Flucloxacillin ), particularly when instrumentation or implants are used means that gentamicin is recommended in addition to Flucloxacillin or Teicoplanin . Gentamicin has both broad spectrum activity against Gram negative bacteria and activity against Staphylococcus aureus and many coagulase negative staphylococci. In addition it penetrates the nucleus pulposus effectively (4).

Spinal surgery with instrumentation
It is debatable whether the spinal instrumentation per se is a risk factor for infection or simply the duration and complexity of the surgery that predisposes to a higher rate of infection. In an animal study of prophylaxis against Staphylococcus aureus infection involving spinal instrumentation, cefazolin was effective at preventing infection compared to no prophylaxis (5). Where spinal surgery involves an implant, the possibility of implant infection with coagulase negative staphylococci and Gram negative bacilli need to be considered – the recommended regimens containing gentamicin will provide an appropriate spectrum of antimicrobial cover.

Since systemic Gentamicin is being recommended, and because of concerns about the evidence to support its efficacy, topical Gentamicin wound irrigation is not currently recommended.

Evidence for the efficacy of prophylaxis, A; choice of agents, D

Provenance

Record:	2070
Objective:
Clinical condition:	Spinal Surgery
Target patient group:	Adults
Target professional group(s):	Secondary Care Doctors Pharmacists
Adapted from:

Evidence base

Barker FG, 2nd. Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery. 2002 Aug;51(2):391-400; discussion -1.
SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
Brown EM, Pople IK, de Louvois J, Hedges A, Bayston R, Eisenstein SM, et al. Spine update: prevention of postoperative infection in patients undergoing spinal surgery. Spine. 2004 Apr 15;29(8):938-45.
Guiboux JP, Ahlgren B, Patti JE, Bernhard M, Zervos M, Herkowitz HN. The role of prophylactic antibiotics in spinal instrumentation. A rabbit model. Spine (Phila Pa 1976). 1998 Mar 15;23(6):653-6.

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists]

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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